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Preface vii

F.A. DAVIS LPN/LVN ADVISORY BOARD

The authors and publisher extend a special thank Kaye Henry, BSN
you to the F.A. Davis LPN/LVN Advisory Board,
Program Director
whose members have provided guidance through
School of Practical Nursing
their experience and expertise:
Georgia Piedmont Technical College
Deborah D. Brabham, PhD, RN, CNE Covington, Georgia
Instructional Program Manager, Frisch Institute Dawn Johnson, DNP, RN, Ed
for Senior Care
Practical Nursing Program Director
Florida State College at Jacksonville
Great Lakes Institute of Technology
Jacksonville, Florida
Erie, Pennsylvania
Mark Donoghue, MS, RN
Paula K. Mundell, MSN, RN
Faculty
Isabella Graham Hart School of Practical Nursing Coordinator, Nursing Program
Rochester, New York Delaware Technical Community College
Dover, Delaware
Shelley Eckvahl, MSN, BSN
Patricia Taylor, MSN-Ed, RN
Lead Instructor
Chaffey College Practical Nursing Coordinator
Chino Hills, California Kapi’olani Community College
University of Hawaii
Marie Hedgpeth, MSN, MHA, RN Honolulu, Hawaii
Practical Nursing Instructor
Robeson Community College
Lumberton, North Carolina
6913_FM_i-xiv 06/08/18 5:44 PM Page viii

Jo Ann Abbott, RN, MSN, DNP
Delaware Technical and Community College
State of Delaware Division of Developmental
Disabilities
Dover, DE
Shelley Eckvahl, RN, MSN
Professor, Vocational Nursing Program
Chaffey Community College
Rancho Cucamonga, CA
Dorothy Eyong, EdD, MSN, RN
Delaware Technical Community College
Dover, DE
Reviewers
Dawn Johnson, DNP, RN, Ed
Director of Nursing
Great Lakes Institute of Technology
Erie, PA
Sonia Rudolph, MSN, APRN, FNP-BC
Associate Professor of Nursing
Jefferson Community & Technical College
Louisville, KY
Donna R. Wallis, MBA, MSN, RN
Director of Vocational Nursing
Baptist Health System
San Antonio, TX

Previous Edition Reviewers

Patti Alford, RN, BSBM Cheryl Gilbert, RN, BHA
Longview, TX Chino, CA

Ruth Fee Blackmore, MSN, RN, CNOR Peggy Grady, RN, ASN
Rochester, NY Griffin, GA

Reneé T. Burwell, AASN, BSN, Deborah B. Harris, BSN, MSN, RN

MSEd, EdD Fishersville, VA
Port Charlotte, FL
Eula Jackson, ADN, BS, MSN,
Joyce Canavan, BS Ed, MSN, RN CNE, PhD
El Paso, TX Evergreen, AL

Tammie Cohen, RN, BSN Linda Johnson, RN, PHN, MSN,

Northport, NY DHA
Pittsburg, CA
Wendy C. Farr, RN, BSN, MSN/Ed,
Ins Ethel Jones, EdS, DSN, RN, CNE
Thomaston, GA Montgomery, AL

Brian Fonnesbeck, RN, MN, BSN, Tammy Krell, MSN, RN

ADN Evanston, WY
Lewiston, ID

viii
6913_FM_i-xiv 06/08/18 5:44 PM Page ix

Previous Edition Reviewers ix

Susan R. Leferson, RN, BSN, MSBA, Cindy Price, MSN, RN

COHC Zanesville, OH
Manassas, VA
Cynthia Roberts, MS, RN
Rimina Lewis, MSN/Ed, RN Rochester, NY
Savannah, GA
Phyllis Rowe, DNP, RN, ANP
Gayla Love, MSN, BSN, RN, CCM Riverside, CA
Griffin, GA
Ellen Santos, MSN, RN, CNE
Kimberly K. McClure, MSN, RN Marlborough, MA
Victoria, TX
Judith M. Shaffer, RN, BSN, MSN/Ed
Carol A. Miller, BSN student
Easton, MA Raleigh, NC

John H. Nagelschmidt, MSN, RN Claudia Stoffel, MSN, RN, CNE

Marlborough, MA Paducah, KY

Diana Nobleza, MSN, RN Kendra Strenth, RN, MSN, DNP, BC

Toms River, NJ Mobile, AL

Sallie Noto, RN, MS, MSN Barbara Taylor, RN, MSN

Scranton, PA DeFuniak Springs, FL

Mary A. Olson, MA, RN Sandra D. Thompson, RN

Saint Paul, MN Princeton, WV

Kristi Pfeil, MSN, RN Peggy Valentine, RN, BSN, MSNc

Victoria, TX Roanoke, VA

Maryellen Picchiello, MS, RN Faye Warner, RN, MSN

Toms River, NJ Waterbury, CT

Jennifer Ponto, RN, BSN

Levelland, TX

Consultants to Previous Editions

Brenda Agee, RN, MSN Gloria Ferritto, RN, BSN, PHN
Georgetown, DE Vista, CA

Ethel Avery, RN, MSN, EdS Frances Francis, RN, BS

Montgomery, AL Hazard, KY

Sharon M. Erbe, RN, BSN, MSN(c) Sue Garland, RN, MSN, ARNP
Hudson Falls, NY Paintsville, KY
6913_FM_i-xiv 06/08/18 5:44 PM Page x

x Consultants to Previous Editions

Nancy T. Hatfield, RN, BSN, MA Betty Richardson, RN, PhD, LPC,

Albuquerque, NM LMFT, CS, CNAA
Austin, TX
Christine D. Herdlick, RN, BA
Marshalltown, IA Robin A. Spidle, RN, PhD
Payson, AZ
Debra Hodge
Beckley, WV Judy Stauder, RN, MSN
Canton, OH
Phyllis Lilly, RN, BSN
Rochester, NY

Maureen L. McGary, RN, MSN, NP-C

Wirtz, VA
6913_FM_i-xiv 06/08/18 5:44 PM Page xi

Table of Contents
UNIT ONE CHAPTER 6 Nursing Process in Mental
Foundations for Mental Health Nursing Health 81
Step 1: Assessing the Patient’s
CHAPTER 1 History of Mental Health
Mental Health 82
Nursing 2
Step 2: Nursing Diagnosis:
The Trailblazers 2
Defining Patient Problems 88
The Facilities 6
Step 3: Planning (Short- and
The Breakthroughs 7
Long-Term Goals) 88
The Law 9
Step 4: Implementations/
Interventions 89
CHAPTER 2 Basics of Communication 13 Step 5: Evaluating Interventions 93
Communication Theory 14
Types of Communication 14 CHAPTER 7 Coping and Defense
Challenges to Communication 16 Mechanisms 96
Therapeutic Communication 19 Coping 96
Adaptive Communication Defense Mechanisms 98
Techniques 24
CHAPTER 8 Mental Health Treatments 104
CHAPTER 3 Ethics and Law 28 Psychopharmacology 105
Professionalism 28 Milieu 114
Ethics 29 Psychotherapies 115
Confidentiality 33 Global Crisis 127
Responsibility 35 Summary 128
Accountability 36
Abiding by the Current Laws 36 CHAPTER 9 Complementary and
Patients’ Rights 37 Alternative Treatment
Patient Advocacy 40 Modalities 132
Community Resources 40 Mind, Body, and Belief 133
Common Complementary
CHAPTER 4 Developmental Psychology and Alternative Treatments 133
Throughout the Life Span 44 Primary Sensory Representation 142
Human Development 44 Summary 143
Developmental Theorists:
Newborn to Adolescence 45
Developmental Theorists:
UNIT TWO
Adolescence to Adulthood 51
Threats to Mental Health
Stages of Human Development 57 CHAPTER 10 Anxiety, Anxiety-Related,
and Somatic Symptom
CHAPTER 5 Sociocultural Influences Disorders 150
on Mental Health 68 Anxiety Disorders 150
Culture 68 Etiology of Anxiety and Stress 151
Ethnicity 71 Differential Diagnosis 152
The Changing Family 72 Types of Anxiety and
Homelessness 74 Anxiety-Related Disorders 152
Economic Considerations 75 Medical Treatment of People
Abuse 77 With Anxiety and
Parenting 77 Anxiety-Related Disorders 157
xi
6913_FM_i-xiv 06/08/18 5:44 PM Page xii

xii Table of Contents

Alternative Interventions for CHAPTER 16 Neurocognitive Disorders:

People With Anxiety and Delirium and Dementia 229
Anxiety-Related Disorders 158 Delirium 229
Nursing Care for People Dementia 231
With Anxiety and Nursing Care of Patients
Anxiety-Related Disorders 158 With Delirium and Dementia 237
Somatic Symptom and Related
Disorders 160 CHAPTER 17 Substance Use and Addictive
Disorders 244
CHAPTER 11 Depressive Disorders 170 Alcohol 247
Types of Depressive Disorders 170 Other Substances 253
Etiology of Depressive Disorders 175 Nursing Care of Patients
Treatment of Depressive With Substance Use
Disorders 175 Disorders (Including Alcohol) 262
Nursing Care of the Patient
With Depressive Disorders 177 CHAPTER 18 Eating Disorders 269
Anorexia Nervosa 270
CHAPTER 12 Bipolar Disorders 181 Symptoms of Anorexia Nervosa 270
Characteristics of Bipolar Treatment of Anorexia Nervosa 271
Disorders 181 Bulimia 272
Etiology of Bipolar Disorders 184 Binge Eating Disorder 275
Treatment of Bipolar Disorders 184 Morbid Obesity 275
Nursing Care of the Patient Nursing Care of Patients
With Bipolar Disorders 187 With Eating Disorders 276

CHAPTER 13 Suicide 191

The Reality of Suicide 191
UNIT THREE
Etiology of Suicide 194
Special Populations
Treatment of Individuals at Risk CHAPTER 19 Childhood and Adolescent
for Suicide 195 Mental Health Issues 284
Nursing Care of the Suicidal Depression, Bipolar Disorder,
Patient 196 and Suicide in Children
and Adolescents 285
CHAPTER 14 Personality Disorders 202 Attention Deficit/Hyperactivity
Types of Personality Disorders 203 Disorder 290
Psychiatric Treatment of Autism Spectrum Disorder 293
Personality Disorders 208 Conduct Disorder 297
Nursing Care of Patients
With Personality Disorders 209 CHAPTER 20 Postpartum Issues in
Mental Health 302
CHAPTER 15 Schizophrenia Spectrum Postpartum Blues 302
and Other Psychotic Postpartum Depression 303
Disorders 216 Postpartum Psychosis 305
Symptoms 218 Nursing Care of Women
Etiology of Schizophrenia 219 With Postpartum Mental
Psychiatric Treatment of Disorders 307
Schizophrenia 220
Nursing Care of the
Schizophrenic Patient 223
6913_FM_i-xiv 06/08/18 5:44 PM Page xiii

Table of Contents xiii

CHAPTER 21 Aging Population 312 Appendices

Alzheimer’s Disease and Other
APPENDIX A Answers and Rationales 347
Cognitive Alterations 315
Cerebrovascular Accident
APPENDIX B Agencies That Help People
(Stroke) 315
Who Have Threats to
Depression in the Elderly 316
Their Mental Health 363
Medication Concerns 317
Paranoid Thinking 317
APPENDIX C Organizations That Support
Insomnia 319
the Licensed Practical/
End-of-Life Issues 319
Vocational Nurse 365
Social Concerns 320
Nursing Skills for Working
APPENDIX D Standards of Nursing
With Older Adults 321
Practice for LPNs/LVNs 367
Restorative Nursing 323
Palliative Care 325
APPENDIX E Assigning Nursing Diagnoses
to Client Behaviors 369
CHAPTER 22 Victims of Abuse and
Violence 329
Glossary 371
The Abuser 330
The Victim 331
Index 379
Categories of Abuse 332
Treatment of Abuse 338
Nursing Care of Victims
of Abuse 339
6913_FM_i-xiv 06/08/18 5:44 PM Page xiv
6913_Ch01_001-012 22/07/18 5:35 PM Page 1

unit ONE

Foundations for
Mental Health
Nursing
6913_Ch01_001-012 22/07/18 5:35 PM Page 2

1 History of Mental
Health Nursing
KEY TERMS LEARNING OUTCOMES
• American Nurses Association 1. Identify the major trailblazers of mental health
• Asylum
nursing.
• Deinstitutionalization
• Free-standing treatment centers 2. Know the basic tenets or theories of the contribu-
• National League for Nursing tors to mental health nursing.
• Psychotropic 3. Define three types of treatment facilities.
4. Identify three breakthroughs that advanced mental
CHAPTER CONCEPTS health nursing.
5. Identify the major laws and the provisions of each
Evidence-Based Practice that influenced mental health nursing.
Health Promotion
Professionalism
Informatics

many volumes. She was born of wealth and was

THE TRAILBLAZERS
Long before people knew what aerobic or anaer-
obic microorganisms were, nurses knew when
to open or close the windows. Nurses helped
women give birth and nursed the babies when
mothers were unable to or when mothers died
during or shortly after childbirth. The first flight
attendants were nurses. For centuries, nurses
have gone about the business of caring for peo-
ple, but they have not always done so quietly.
Who were the risk-takers? Who advocated on
behalf of the patient and the profession? In times
when nursing was considered “women’s work”
and women were not politically active, the major
trailblazers were female.
Florence Nightingale
Florence Nightingale (1820–1910) (Fig. 1.1) has
been called the founder of nursing. Her story and
her contributions are numerous enough to fill
highly educated. When she was very young, she
realized she wanted to be a nurse, which did not
please her parents. Conditions in hospitals were
poor, and her parents wanted her to pursue a life
as a wife, mother, and society woman.
Nightingale worked hard to educate herself in
the art and science of nursing. Her mission to help
the British soldiers in the Crimean War earned her
respect around the world as a nurse and adminis-
trator. This was no easy task because many of the
soldiers at the Barrack Hospital at Scutari resented
her intelligence and did what they could to under-
mine her work.
The relationship between sanitary conditions
and healing became known and accepted due to
Nightingale’s observations and diligence. Within
6 months of her arrival in Scutari, the mortality
rate dropped from 42.7% to 2.2% (Donahue,
1985, p. 244). She insisted on proper lighting,
diet, cleanliness, and recreation. She understood
that the mind and body work together and that

2
6913_Ch01_001-012 22/07/18 5:35 PM Page 3
Chapter 1
FIGURE 1.1 Florence Nightingale at work during
the Crimean War.
cleanliness, the predecessor to today’s sterile tech-
niques, is both a major barrier to infection and a
gateway to healing. She carefully observed and
documented changes in the conditions of the sol-
diers, which led to her adulation as “The Lady
with the Lamp.”
Santa Filomena
by Henry Wadsworth Longfellow
Whene’er a noble deed is wrought,
Whene’er is spoken a noble thought,
Our hearts, in glad surprise,
To higher levels rise.
The tidal wave of deeper souls
Into our inmost being rolls,
And lifts us unawares
Out of all meaner cares.
Honour to those whose words or deeds
Thus help us in our daily needs,
And by their overflow
Raise us from what is low!
Thus thought I, as by night I read
Of the great army of the dead,
The trenches cold and damp,
The starved and frozen camp,
The wounded from the battle-plain,
In dreary hospitals of pain,
The cheerless corridors,
The cold and stony floors.
Lo! in that house of misery
A lady with a lamp I see
Pass through the glimmering gloom,
And flit from room to room.
And slow, as in a dream of bliss,
The speechless sufferer turns to kiss
Her shadow, as it falls
Upon the darkening walls.
History of Mental Health Nursing 3
As if a door in heaven should be
Opened and then closed suddenly,
The vision came and went,
The light shone and was spent.
On England’s annals, through the long
Hereafter of her speech and song,
That light its rays shall cast
From portals of the past.
A Lady with a Lamp shall stand
In the great history of the land,
A noble type of good,
Heroic womanhood.
Nor even shall be wanting here
The palm, the lily, and the spear,
The symbols that of yore
Saint Filomena bore.
Nightingale was a crusader for the improve-
ment of care and conditions in the military and
civilian hospitals in Britain. Among her books
are Notes on Hospitals (1859), which deals with
the relationship of sanitary techniques to medical
facilities; Notes on Nursing (1859), which was the
most respected nursing textbook of its day; and
Notes on Matters Affecting the Health, Efficiency
and Hospital Administration of the British Army
(1857) (Donahue, 1985, p. 248).
The first formal nurses’ training program, the
Nightingale School for Nurses, opened in 1860.
The goals of the school were to train nurses to work
in hospitals, to work with the poor, and to teach.
Many of these nurses cared for people in their
homes, an idea that is still gaining in popularity and
professional opportunity for nurses.
Dorothea Dix
Dorothea Dix (1802–1887) (Fig. 1.2) was a school-
teacher, not a nurse. She believed that people did
not need to live in suffering and that society had a
responsibility to aid those less fortunate. Her pri-
mary focus was the care of prisoners and the
mentally ill. She lobbied in the United States and
Canada for the improvement of care standards for
the mentally ill and even suggested that govern-
ments take an active role in providing persons with
mental illness help with finances, food, shelter, and
other areas of need. Dix learned that many crimi-
nals were also mentally ill; a theory that is borne
out in studies today. Because of the efforts of
Dorothea Dix, 32 states developed asylums or
“psychiatric hospitals” to care for the mentally ill.
There is a monument to her that symbolized her
efforts on the Women’s Heritage Trail in Boston.
6913_Ch01_001-012 22/07/18 5:35 PM Page 4

4 UNIT ONE Foundations for Mental Health Nursing

Linda Richards
FIGURE 1.2 Dorothea Dix. America's First Trained Nurse
Born in Potsdam, 1841
FIGURE 1.3 Linda Richards.

Linda Richards
While Dorothea Dix sought political help for men- Effie Jane Taylor
tal health care, a nurse named Linda Richards Euphemia (Effie) Jane Taylor (1874–1970) (Fig. 1.4)
(1841–1930) (Fig. 1.3) worked to upgrade nursing initiated the first psychiatric program of study
education. She was one of the first five students for nurses in 1913. She is also well known for
enrolled in an American nursing program, and in her development and implementation of patient-
1882 she opened the Boston City Hospital Training centered care, putting emphasis on the emotional
School for Nurses to teach the specialty of caring and intellectual life of the patient. Effie Taylor
for the mentally ill. By 1890, more than 30 asylums
in the United States had developed schools for
nurses. Linda Richards was among the first nurses
to teach the planning of nursing care for patients.
In cooperation with the American Nurses Asso-
ciation (ANA) and the National League for
Nursing (NLN), she was instrumental in develop-
ing textbooks specifically for nurses that had stated
objectives for outcomes of nursing education and
patient care.

Harriet Bailey
The first textbook focusing on psychiatric nursing
was written in 1920 by Harriet Bailey. It included
guidelines for nurses who provided care for those
with a mental illness. Bailey understood that nurses
caring for these patients needed proper training.
After she published her book, the NLN began
requiring all student nurses have a clinical rotation FIGURE 1.4 Effie Jane Taylor (From Yale University,
in a psychiatric setting (Videback, 2013). Harvey Cushing/John Hay Whitney Medical Library).
6913_Ch01_001-012 22/07/18 5:35 PM Page 5

Chapter 1 History of Mental Health Nursing 5

received a diploma from Johns Hopkins School of

Nursing and went on to become a nursing profes-
sor in psychiatry (American Association for the
History of Nursing, Inc., 2017).

Mary Mahoney
Mary Mahoney (1845–1926) (Fig. 1.5) is con-
sidered to be America’s first African American
professional nurse. She contributed primarily
to home health care and promoted the acceptance
of African Americans in the field of nursing. Dur-
ing Mahoney’s career, segregation made it im-
possible for African American students to attend
nursing school with white students. Instead, African
American students attended separate schools such
as Spelman Seminary (currently known as Spel-
man College) in Georgia and Tuskegee Institute in
Alabama. An award in Mahoney’s name is pre-
sented at the annual ANA convention to a person
who has worked to promote equal opportunity for
FIGURE 1.6 Hildegard Peplau.
minorities in nursing.

Hildegard Peplau
Dr. Hildegard Peplau (1909–1999) (Fig. 1.6) was a
nurse ahead of her time. She believed that nursing
is multifaceted and that the nurse must educate and
promote wellness as well as deliver care to the ill. In
her book Interpersonal Relations in Nursing (1952),
Peplau brought together interpersonal theories from
psychiatry and melded them with theories of nursing
and communication. She believed that nurses work
in society—not merely in a hospital or clinic—and
that they need to use every opportunity to educate
FIGURE 1.5 Mary Mahoney.
the public and act as role models in physical and
mental health. Peplau saw the nurse as:
1. Resource person. Provides information.
2. Counselor. Helps patients to explore their
thoughts and feelings.
3. Surrogate. By role-playing or other means,
helps the patient to explore and identify feel-
ings from the past.
4. Technical support. Coordinates professional
services (Peplau, 1952).
In addition to this, Peplau believed in building a
collaborative therapeutic relationship between the
nurse and the patient. In her book, she cites four
stages of this relationship (Peplau, 1952):
1. Orientation. Patient feels a need and a will to
seek out help.
2. Identification. Expectations and perceptions
about the nurse–patient relationship are identified.
3. Exploration. Patient will begin to show
motivation in the problem-solving process, but
some testing behaviors may be seen; patient
may have a need to “test” the nurse’s commit-
ment to his/her individual situation.
4. Resolution. Focus is on the patient developing
self-responsibility and showing personal growth.
At Rutgers University in 1954, Peplau developed
the first graduate-level nursing program to provide
training for clinical nurse specialists in psychiatric
nursing.
6913_Ch01_001-012 22/07/18 5:35 PM Page 6

6 UNIT ONE Foundations for Mental Health Nursing

Hattie Bessent
In the early 1980s, the National Institute of Mental
Health (NIMH) granted money to be used for the
education and research of minority nurses who
were choosing to upgrade to master’s and doctorate
levels of practice. Dr. Hattie Bessent (1908–2015)
(Fig. 1.7) is credited with the development and
directorship of that program. In 2008, the ANA pre-
sented Bessent with its Hall of Fame Award.
Bessie Blount Griffin
Bessie Blount Griffin (1914–2009) was a practical
nurse, physical therapist, and forensic scientist
specializing in handwriting. She also understood
the mental stress of soldiers who lost their limbs
during World War II. These soldiers wanted to FIGURE 1.7 Hattie Bessent.
write letters to their loved ones, but without their
hands, this was difficult. Griffin assisted these
soldiers to learn how to write with their mouths
and, in some cases, their feet (R.F. Anwar, personal CRITICAL THINKING
communication, October 2007). QUESTION
Nursing’s “trailblazers” were risk-takers whose
efforts expanded what it meant to be a nurse.
TOOL BOX One responsibility of a professional nurse is to
Nursing’s Trailblazers give something back to our profession. How will
For more about each of these trailblazers, see the you become a trailblazer? What steps should
Web sites below. nursing, as a whole, take to strengthen the pro-
Florence Nightingale fession? What criteria should be important when
http://www.biography.com/people/florence- deciding what level of preparation is required for
nightingale-9423539 a nurse specializing in mental health?
Dorothea Dix
http://www.biography.com/people/dorothea-
dix-9275710#synopsis
Linda Richards CLASSROOM ACTIVITY
http://www.aahn.org/gravesites/richards.html Research one trailblazer in nursing. On an as-
Effie Jane Taylor signed day, come to class with a prop and a
http://www.hopkinsmedicine.org/psychiatry/ brief explanation of the trailblazer and his or her
about/anniversary/nurses/effie_taylor.html contribution(s) to nursing.
Mary Mahoney
http://www.biography.com/people/mary-
mahoney-41021
Hildegard Peplau THE FACILITIES
http://currentnursing.com/nursing_theory/
interpersonal_theory.html People who have mental illnesses are in all walks
Hattie Bessent of life; statistics say that about one in three
http://minoritynurse.com/dr-hattie-bessent- Americans will experience some form of mental
inducted-into-ana-hall-of-fame/ illness at some point in life. The trailblazers in
Bessie Blount Griffin nursing realized that mental illness is different
http://americacomesalive.com/2 016/02/11/ from medical-surgical disorders. They understood
bessie-blount-griffin-physical-therapist-and- that persons with moderate to severe mental dis-
inventor/ orders were often better served through care in
special facilities.
6913_Ch01_001-012 22/07/18 5:35 PM Page 7
Chapter 1
Asylums
Early on, these special facilities were called asy-
lums, which Webster Online defines as “an institu-
tion for the care of the needy or sick and especially
of the insane.” Patients in asylums were frequently
treated less than humanely. Custodial care was pro-
vided, but patients were often heavily medicated.
Nutritional and physical care was minimal, and
often these patients were volunteered for various
forms of experimentation and research.
One of the largest asylums in the United States
was known as ByBerry, later renamed Philadelphia
State Hospital (Fig. 1.8). This facility reportedly
provided inhumane treatment to its patients. With
the onset of deinstitutionalization and due to the
poor conditions, this facility saw its last patient
in 1990.
Hospitals
As treatment facilities evolved, the term “asylum”
and the connotations associated with it became un-
popular. In 1753, Pennsylvania Hospital established
a facility to treat those with mental disorders. The
hospital was established by Dr. Thomas Bond and
Benjamin Franklin. Until the Community Mental
Health Act of 1963 was passed, housing of this
clientele was primarily handled by individual state
hospital systems.
Today, hospitals handle patients with psycholog-
ical needs according to the size of the hospital and
its resources. To comply with regulations surround-
ing mental health issues, these patients may be seen
in a hospital emergency room and then referred to
other clinics or hospitals. Communities large enough
to support such programs may provide in-house
FIGURE 1.8 ByBerry, later to be renamed
Philadelphia State Hospital (Courtesy of Robynn
Anwar).
History of Mental Health Nursing 7
mental health treatment as well as outpatient treat-
ment and aftercare. Metropolitan areas commonly
provide treatment via several options, including hos-
pitals and free-standing treatment centers.
Free-Standing Facilities
Free-standing treatment centers may be called
detoxification (detox) centers, crisis centers, or
similar names. Most people are familiar with the
Betty Ford Center. Many free-standing treatment
centers provide care ranging from crisis-only to
more traditional 21-day stays. As with the Betty
Ford Center, a stay can last up to 120 days. This,
too, depends largely on the size and needs of the
individual community. More discussion on the
types of treatment facilities occurs in the section
on The Law.
THE BREAKTHROUGHS
It was not until 1937 that formal clinical rotations
in mental health began for nursing students. Today,
these rotations are required for students in all nurs-
ing programs. In 1955, theory relating to mental
health nursing became a requirement for licensure
for all nurses. Students in a practical or vocational
nursing program are taught mental health theory
and participate in observational clinical rotations.
However, their clinical rotation differs from that
of a BSN-trained student nurse. In 1955, theory
relating to mental health nursing became a require-
ment for licensure for all nurses.
Throughout the 1800s and early 1900s, progress
was made in developing humane, effective treat-
ment of mental illnesses. With the best knowledge
available to them as a profession, nurses were
forward thinkers in providing specialized care to
people unfortunate enough to have illnesses
different from the tuberculosis, smallpox, and
influenza that filled hospitals. Unlike physical
illnesses, no medications existed to treat mental
disorders. At that time, no one had been able to find
pharmacologic help for people with emotional,
behavioral, or physical brain disorders. That would
change in the 1950s.
Psychotropic Medications
In the early 1950s, chemists were experimenting
with combinations of chemicals and their effects
on people. In 1955, a group of psychotropic medi-
cations called phenothiazines (see Chapter 8) was
6913_Ch01_001-012 22/07/18 5:35 PM Page 8
8 UNIT ONE Foundations for Mental Health Nursing
discovered to have the effect of calming and tran-
quilizing people. One well known phenothiazine
is chlorpromazine HCl (Thorazine). What a world
of possibility this medication opened for people
living with mental disorders and for those caring
for them! Suddenly, it was possible to control
unwanted behaviors (to a degree), and patients
were able to function more independently. Other
forms of therapy became more effective because
medicated patients were able to focus. Some
patients improved so dramatically that it was no
longer necessary for them to remain hospitalized
and dependent on others. Between the mid-1950s
and the mid-1970s, the number of patients hospi-
talized with mental illnesses in the United States
was cut approximately in half, mainly because of
the use of psychotropic drugs.
Deinstitutionalization
Phenothiazines were so effective that state hospitals
and other facilities dedicated to the care and treat-
ment of people with mental illness saw a large de-
cline in population. It became costly to run these
large buildings and continue to employ staff. The
combination of these effects, as well as new laws
pertaining to the care of the mentally ill, resulted in
a movement called deinstitutionalization. People
who had formerly required long hospital stays were
now able to leave the institutions and return to their
communities. Once discharged, some went to group
homes, and some returned home. Unfortunately,
others faced homelessness. Deinstitutionalization
was and still is a controversial issue, but it was a
huge step in returning a sense of worth, ability, and
independence to those who had been dependent on
others for their care for so long.
CRITICAL THINKING
QUESTION
The law requires that people who have mental
illnesses be treated using the “least restrictive alter-
native.” Deinstitutionalization allows these people
to live among us in the community. Consider the
following scenario: Your city has just purchased
the house next door to you, and the plan is to
develop this into a halfway house for women who
have been child abusers. You are the parent of a
3-year-old, and you are also a mental health nurse.
What would you do? What are your thoughts and
feelings about this situation?
Organizations for Mental Health
Nurses and Others
A natural progression from the breakthroughs that
were happening in nursing was the development
of organizations for nurses. The ANA is recog-
nized as an organization for registered nurses
(RNs). One of its goals is to promote standardiza-
tion of nursing practice in the United States. The
ANA also promotes the certification of nurses who
meet specific criteria. The concept of psychiatric
nurse specialists, clinicians, or advanced practice
nurses is a result of the work of the ANA. The
American Psychiatric Nurses Association provides
leadership in recommending standards of care
for RNs who care for people with mental illness.
In addition to other organizations, there is the
National Alliance on Mental Illness (NAMI)
whose commitment is making lives of Americans
with mental health disorders better.
CLASSROOM ACTIVITY
List the standards of psychiatric/mental health clin-
ical nursing practice and give an example of a
nursing behavior or action that correlates with
each standard.
http://www.austincc.edu/adnlev3/rnsg2213
online/intro/standards
http://www.nursingworld.org/MainMenu
Categories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Vol-20-2015/No1-Jan-
2015/2014-Scope-and-Standards-for-Psychiatric-
Mental-Health.html
Specific to the licensed practical/vocational
nurse are two organizations: the National Associa-
tion of Licensed Practical Nurse (NALPN) (for-
merly known as National Federation of Licensed
Practical Nurses [NFLPN]) and the National
Association for Practical Nurse Education and
Service (NAPNES). NALPN welcomes licensed
practical nurses (LPNs) and licensed vocational
nurses (LVNs) in the United States. The NALPN
has a published set of Nursing Practice Standards
for the LPN (see Appendix D).
NAPNES was founded by practical nurse edu-
cators in 1941 and identifies itself as the world’s
oldest nursing organization dedicated exclusively
to the promotion of quality nursing service through
the practice of LPNs and LVNs. NAPNES is a
multidisciplinary organization of individuals,
6913_Ch01_001-012 22/07/18 5:35 PM Page 9

Chapter 1 History of Mental Health Nursing 9

facilities, and schools that advocates for profes- Federation of Licensed Practical Nurses): http://
sional practice of the practical and vocational nurse. nalpn.org
NAPNES: National Association for Practical Nurse
Education and Services: https://napnes.org
TOOL BOX NCEMNA: National Coalition of Ethnic Minority
Organizations for Practical and Vocational Nurses Nurse Associations: http://ncemna.org/
AAPINA: Asian American / Pacific Islander Nurses
Learn more about NALPN and NAPNES at their
Association, Inc.: http://aapina.org/
Web sites.
NANAINA: National Alaska Native American
National Association of Licensed Practical Nurse
Indian Nurses Association: http://nanaina-
(NALPN) http://nalpn.org
nurses.org/
National Association for Practical Nurse Education
NAHN: National Association of Hispanic
and Service, Inc. (NAPNES) www.napnes.org
Nurses: http://www.nahnnet.org/
NBNA: National Black Nurses Association:
www.nbna.org/
The National Coalition of Ethnic Minority
PNAA: Philippine Nurses Association of America:
Nurse Associations (NCEMNA) is made up of five
http://www.mypnaa.org/
national ethnic nurse associations: Asian American/
AAMN: American Assembly for Men in Nursing:
Pacific Islander Nurses Association, Inc. (AAPINA),
http://aamn.org/
National Alaska Native American Indian Nurses
Association, Inc. (NANAINA), National Associa-
tion of Hispanic Nurses, Inc. (NAHN), National
Appendix C of this text provides more contact
Black Nurses Association, Inc. (NBNA), and Philip-
information for these and other agencies designed
pine Nurses Association of America, Inc. (PNAA).
to promote and assist nurses, particularly at the
Goals include advocating for equity and justice in
LPN and LVN level of preparation.
nursing and health care for ethnic minority popu-
lations and endorsement of best practice models
for nursing practice, education, and research for
THE LAW
minority populations.
Over the years, many advancements have been
The American Assembly for Men in Nursing
made in medicine and in the treatment of mental
(AAMN) provides a framework for male nurses,
disorders. But mental-health ethical practices
as a group, to meet to discuss and influence fac-
have remained a challenge. Ethical considera-
tors that affect men as nurses. Among its objec-
tions, especially, abound in the rights of people
tives is to encourage men of all ages to become
with mental illness. Psychotropic (also known
nurses and to support men who are nurses to grow
as psychoactive) medications benefit many patients,
professionally. Like other professional nursing
but their side effects are not always pleasant.
organizations, AAMN advocates for continued
As more drugs have been developed, more ques-
research, education, and dissemination of infor-
tions have arisen: How much medication is too
mation about men’s health issues, men in nursing,
much? Do we keep patients completely sedated?
and nursing knowledge at the local and national
Which is worse—the illness or the medication?
levels.
Other concerns have arisen, such as the relation-
ship of some psychotropic drugs to diabetic
mellitus.
TOOL BOX
As a result of these concerns, it was necessary
Nursing Organizations for the national government to more closely regu-
ANA: American Nurses Association: www.nursing late mental health care. A series of laws governing
world.org/ various aspects of care for persons with mental
APNA: American Psychiatric Nurses Association: illnesses were passed. The laws have changed
www.apna.org/ somewhat and have been renamed in some cases,
NLN: National League for Nursing: www.nln.org/ but the collective intention is to provide funding,
NALPN: National Association of Licensed Practi- treatment, and ethical care for this vulnerable seg-
cal Nurse (formerly known as the National ment of society.
6913_Ch01_001-012 22/07/18 5:35 PM Page 10
10 UNIT ONE Foundations for Mental Health Nursing
CRITICAL THINKING
QUESTION
Your employer has announced that your company
is changing its medical insurance policy. The
company will be providing employees with a set
amount of money to spend on insurance benefits.
The three insurance plans you have to choose
from offer either family coverage or mental health
services. You are a single parent with two
preschoolers. You also have a diagnosis of bipo-
lar disorder for which you need medication, ther-
apy, and periodic hospitalization. What will you
choose, and why will you choose it?
Hill-Burton Act
In 1946, Senators Lister Hill and Harold Burton
collaborated to create the Hill-Burton Act, a fed-
eral law. The first major law to address mental
illness, this Act provided money to build psychi-
atric units in hospitals. Today, people with mental
illness who lack insurance coverage and who live
below the poverty level know they will not be
turned away because of financial difficulties, as
they are protected by the Hill-Burton Act.
National Mental Health Act of 1946
The National Mental Health Act of 1946 was a
result of the first Congress held after World War II.
It provided money for nursing and several other
disciplines for training and research in areas
pertaining to improving treatment for the men-
tally ill. The NIMH was established as part of the
National Mental Health Act of 1946. The NIMH
continuously updates the public on mental health
issues. Since 1999, NIMH has been researching
autism. In addition, the agency started the Army
Study to Assess Risk and Resilience in Service
Members (Army STARRS). The Army STARRS
looks at the many challenges faced by those who
encounter battle and the coping strategies used
to address these challenges.
Community Mental Health Centers Act
of 1963
The Community Mental Health Centers Act resulted
from President John F. Kennedy’s concern for the
treatment of the mentally ill. The Act’s main purpose
was to provide a full set of services to the people
living in the community. These services were to
include inpatient care, outpatient care, emergency
care, and education. This was to be a national effort,
funded federally at first. The goal was for the centers
to generate enough services so that, eventually, the
community could support it financially.
In 1981, the Act was amended in Congress.
The Omnibus Budget Reconciliation Act (OBRA)
was the amendment that allows money for mental
health to be allocated differently. The bill did not
do away with mental health services in the com-
munity, but it provided less funding. Currently
there is less money available in the federal budget
for mental health, and that money can be withheld
at any time. Unfortunately, with the turmoil in
the insurance and health-care delivery systems
today, mental health benefits are often among the
first services to be cut back or eliminated.
Patient Bill of Rights
In 1980, the image of “the patient” was changing.
The Civil Rights Movement of the 1960s began
the provision of rights for all groups of people.
Patients were beginning to be identified as “clients,”
who purchase services from health-care providers.
Persons of very young or very old age and persons
with certain physical, intellectual, or communica-
tion difficulties became politically recognized as
“vulnerable.” The outcome was the development
of the Patient Bill of Rights, which is discussed in
more detail in Chapter 3.
Affordable Care Act
In March 2010, President Barack Obama signed a
bill allowing citizens and non-citizens to purchase
health insurance (Siskin & Lunder, 2016) through
the Patient Protection and Affordable Care Act,
known as the Affordable Care Act (ACA). The new
bill recognized the needs of people with mental
health challenges and established mental health care
as an essential part of complete health coverage.
TOOL BOX
Community Mental Health Act 1963
To read more about the Community Mental Health
Act, explore these Web sites.
www.mass.gov/eohhs/gov/departments/dmh/
about-the-department-of-mental-health.html
Omnibus Budget Reconciliation Act www.gpo.
gov/fdsys/pkg/BILLS-103hr2264enr/pdf/
BILLS-103hr2264enr.pdf
6913_Ch01_001-012 22/07/18 5:35 PM Page 11
Chapter 1
CLINICAL ACTIVITY
Discussion Questions: In clinical post-conference,
discuss your answers to these questions.
1. Identify ways that (a) the delivery of psychiatric/
mental health nursing and (b) roles, functions,
activities, and settings have changed.
2. What issues or trends do you anticipate in
psychiatric/mental health in the future?
Key Points
■ Mental health nursing has a long and rich
history. It has evolved from very rudimentary
skills before the time of Florence Nightingale
to the specialty area of nursing it is today.
■ Patients with mental illness are treated in
many different types of facilities, depending
on the diagnosis and the availability of care in
a particular community.
■ The 1950s were important years in the mental
health field. The first psychotropic medications
were developed, making it possible for people
to return to their homes and communities
(deinstitutionalization). These medications
also allowed other treatments to be more
effective.
REVIEW QUESTIONS
Multiple Choice Questions
1. The main goal of deinstitutionalization was to
1. Let all mentally ill people care for
themselves.
2. Return as many people as possible to a
“normal” life.
3. Keep all mentally ill people in locked
wards.
4. Close all community hospitals.
History of Mental Health Nursing 11
SAFE, EFFECTIVE NURSING
CARE (SENC)
Study mental health nursing theories
Promote mental health care
Review the Nurse Practice Act and Scope of
Practice of the state where practicing
Advocate for patients
Respect Patient’s Bill of Rights
Join nursing organizations
■ Nurses at all levels of preparation are integral
parts of the mental health treatment team. Our
observations, documentation, and interpersonal
skills make nurses effective tools in patient care.
■ Since 1955, all nursing curricula are required
to provide mental health theory.
■ A series of laws over the past 70 years have
provided for money, education, research, and
improvements in the care of the mentally ill.
Financial difficulties in the insurance and
health-care industries contribute to cutbacks
in money and services for care and treatment
of the mentally ill.
■ The Affordable Care Act was signed March
2010.
2. A major breakthrough of the 1950s that
assisted in the deinstitutionalization
movement was
1. The Community Mental Health
Centers Act
2. The Nurse Practice Act
3. The development of psychotropic
medications
4. Electroshock therapy
Continued
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12 UNIT ONE Foundations for Mental Health Nursing

REVIEW QUESTIONS continued

3. The set of regulations that dictates the scope 7. In the past, facilities that housed patients who
of a nurse’s professional duties is called were needy, sick, or insane were known as
1. National League for Nursing 1. Detox centers
2. American Nurses Association 2. Asylums
3. Patient Bill of Rights 3. Outpatient clinics
4. Nurse Practice Act 4. Hospitals
4. As a result of deinstitutionalization and 8. What institute was established as a result of
changes in the health-care delivery system, the National Mental Health Act of 1946?
nurses can expect to care for people with 1. NLN
mental health issues in which of the 2. NFLPN
following settings? 3. NAHN
1. Psychiatric hospitals only 4. NIMH
2. Outpatient settings only 9. Florence Nightingale’s focus in the Crimean
3. Medical-surgical hospital settings War was
4. All of the above 1. Mental health
5. Which of the following trailblazers in nurs- 2. Upgrading education
ing was not a nurse? 3. Clean environment
1. Hildegard Peplau 4. Writing care plans
2. Linda Richards 10. The first psychotropic medications were
3. Harriet Bailey introduced in the
4. Dorothea Dix 1. 1950s
6. Which of the following nursing organiza- 2. 1930s
tions specifically represent minority nurses? 3. 1980s
(Select all that apply.) 4. 1920s
1. NACE
2. AAPINA
3. NAPNES
4. PNAA
5. NANAINA

1.2, 2.3, 3.4, 4.4, 5.4, 6.2, 4, 5, 7.2, 8.4, 9.3, 10.1
Review Questions Answer Key

Web Resources
HealthCare.gov National Alliance on Mental Illness
https://www.healthcare.gov/coverage/mental-health- http://www.nami.org/
substance-abuse-coverage/ National Institute of Mental Health
Hill-Burton Act www.nih.gov/about/almanac/organization/NIMH.htm
https://www.hrsa.gov/gethealthcare/affordable/
hillburton/
6913_Ch02_013-027 22/07/18 5:34 PM Page 13

2 Basics of
Communication
KEY TERMS LEARNING OUTCOMES
• Adaptive communication 1. Identify three components needed to communicate.
• Aggressive communication
2. Differentiate between effective and ineffective
• Aphasia
• Assertive communication communication.
• Communication 3. Identify six types of communication.
• Communication block 4. Identify five challenges to communication.
• Dysphasia 5. Identify common blocks to therapeutic
• Hearing impaired communication.
• Ineffective communication
• Laryngectomy
6. Identify common techniques of therapeutic
• Message communication.
• Neurolinguistic programming 7. Demonstrate various communication styles.
• Nonverbal communication 8. Identify five adaptive communication techniques.
• Receiver
• Sender
• Social communication
• Therapeutic communication
• Verbal communication
• Visually impaired

CHAPTER CONCEPTS
Sensory Perception
Health Promotion
Communication
Safety

Humans communicate. Everything people do or People of different cultures communicate

say has meaning. Sometimes, a person’s words
and actions send different messages. For example,
Sally and Jim meet for shift report in the morning.
Sally’s eyes are red and swollen, and she is unusu-
ally quiet. Jim asks her if something is wrong, and
she responds, “No, everything is just fine.” Jim
observed changes in Sally’s behavior and appear-
ance that indicate there’s a problem. But Sally
verbally communicated that nothing was wrong.
What is the real message?
differently. Men and women communicate dif-
ferently. People who have hearing impairments
communicate differently from people who do
not. People in the medical professions commu-
nicate differently from people in business pro-
fessions by using medical terminology rather
than business terminology. People communicate
all the time in everything they do. Communication
is the ongoing process of sending and receiving
messages.

13
6913_Ch02_013-027 22/07/18 5:34 PM Page 14
14 UNIT ONE Foundations for Mental Health Nursing
COMMUNICATION THEORY
Sender, Receiver, and Interpretation
of Message
One of the challenging parts of communicating with
others is that the process requires three parts: a
sender, a message, and a receiver (Fig. 2.1). That
means the sender is only partially responsible for the
communication. In the above scenario, Sally cannot
totally control Jim’s interpretation of her message.
Sally is the sender, sending a message to Jim, the
receiver. As it turns out, Sally is a victim of severe
allergies. She was visiting her friend who has cats.
Sally is very allergic to cats, and the redness and
swelling of her eyes were symptoms of her allergic
response. She simply did not wish to burden Jim
with her problem during shift report, so she opted
to respond by telling him everything was “just fine.”
CLASSROOM ACTIVITY
What was your initial interpretation of what Sally
was communicating? On what did you base
your interpretation? What “spoke” louder to you:
Sally’s words or her actions and appearance?
What is the danger in making an assumption
about Sally’s message?
It is very important for the sender and receiver
to double-check each other’s understanding of the
message. In nursing, this is crucial because nurses
use their own professional “language”; when deal-
ing with the health and safety of patients, nurses
need to be very sure to avoid “mixed” or “missed”
messages.
TYPES OF COMMUNICATION
Verbal and Written Communication
Verbal communication is the process of exchang-
ing information by the spoken or written word. It
is, therefore, the subjective part of the communi-
cation process. In the example given earlier,
Sender Sends Message to Receiver
FIGURE 2.1 A basic flow of communication.
Sally’s reply that “everything is just fine” is an
example of verbal communication. The expertise
a nurse develops in the areas of verbal and written
communication is largely responsible for the cred-
ibility of that nurse. Critical thinking is essential
to understanding Sally’s reply.
NEEB’S TIP
The meaning of a word or expression can
change from one generation to the next or from
one group of people to another. For example,
in a class discussion on words and gestures and
what they mean, one African American female
student spoke up. She shared with the class that
“gals” in her world was considered a demean-
ing term for an African American woman. How-
ever, in the 1950s and 1960s, being one of
the “guys” or the “gals” was a good thing. It
demonstrated acceptance and belonging to
one’s social group.
Nonverbal Communication
Nonverbal communication consists of people’s
actions, tone of voice, the way they use their
body, and their facial expressions. Nonverbal
communication has a greater influence on com-
munication than verbal communication does.
However, it is more subjective because nonverbal
communication can be interpreted in many differ-
ent ways by the receiver (Fig. 2.2). In the example
above, Sally’s body language communicated that
she was not “fine.”
FIGURE 2.2 Nonverbal communication is estimated
to be 70% of the message we send. The old saying
is true: A picture is worth a thousand words (Courtesy
of Robynn Anwar).
6913_Ch02_013-027 22/07/18 5:34 PM Page 15
Chapter 2
The meaning of nonverbal communication
varies by culture as well. Common hand gestures
can have wildly different meanings. For example,
in the United States, making the “OK” sign with
one’s fingers is a sign of encouragement, agree-
ment, or congratulations. This same gesture is a
vulgarity in other cultures.
CULTURAL
CONSIDERATIONS
Note the diverse cultures and generations in
your community and identify a common gesture
that you use that means something different to
others.
People can learn from each other every day.
Nurses, especially, need to be alert for terms or
gestures that make their patients uncomfortable.
They must make a conscious effort not to use those
words when in the company of those they may
offend (Box 2.1).
Aggressive Communication Versus
Assertive Communication
The terms aggressive and assertive are sometimes
used interchangeably in American culture, but they
have very different meanings.
Aggressive Communication
Aggressive communication is communication
that is not self-responsible. Aggressive statements
most often begin with the word “you.” Aggressive
communication, like aggressive behavior, is meant
to harm another person. It is a form of the defense
mechanism projection, or blaming, and it attempts
to put responsibility for the aggressor’s feelings on
the other person. (For more about defense mecha-
nisms, see Chapter 7.) Aggressive communication
can be nonverbal. A person’s tone, vocal pitch, or
body language can be aggressive.
Example
“You make me so angry when you don’t help with
the housework!”
Assertive Communication
Assertive communication, on the other hand, is
self-responsible. Assertive statements begin with
the word “I.” They express the speaker’s thoughts
and feelings honestly.
Basics of Communication 15
Box 2.1 Examples of
Communication
With Cultural
Implications
Words that are seemingly harmless to some
people can be very hurtful to others. People
do not usually know that until they take the
time to ask. These are examples of commu-
nication that may have different cultural im-
plications. How many more can your class
identify?
• Eye contact with strangers or those in
perceived positions of power or respect is
not considered appropriate among some
populations.
• Hand gestures may communicate differ-
ent meanings to different groups of
people.
• Slang terms may be inappropriate or
offensive, or may exclude people who
do not understand the meaning of
the word.
• Gender-reference terms such as “you guys”
may offend people when the group is
mixed or not male.
• African American or Arab American women
displayed in subservient roles may offend
members of these groups.
• Some media reports and reference sources
may distort or omit important contributions
of minorities.
Example
“I feel angry when you don’t help with the
housework.”
Assertive behavior and communication are
techniques of personal empowerment. People
choose to think or feel a certain way; others do
not have the power to make people think or feel
anything they do not choose to think or feel. Say-
ing “I think” or “I feel” helps to keep people in
control of their emotions, while allowing honest,
open expression of the feelings they have as a
result of someone else’s behavior. The feelings and
thoughts belong to the person choosing them, not
to anyone else.
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16 UNIT ONE Foundations for Mental Health Nursing
CRITICAL THINKING
QUESTION
Write one feeling statement and one thinking
statement for the following situation: A coworker
who is a BSN-prepared nurse routinely comes late
to work and takes long breaks, causing patients
to have unsafe care and you to have extra work.
You speak to your nurse manager, who appears
to ignore your concerns, so you approach the
coworker.
CRITICAL THINKING
QUESTION
Turn the following aggressive statements into
assertive statements.
• “You make me so angry when you stop at the
bar before you come home.”
• “You always take the ‘easy’ assignment, and
that’s not fair.”
• “Mark always gets the days off he asks for;
why can’t I?”
Social Communication
Social communication is the day-to-day interac-
tion people have with personal acquaintances. For
example, teenagers usually communicate with
their peer group in a different manner than they do
with their parents. So, too, do nurses communicate
differently with their patients than they do with
their friends or family.
Nurses may use slang or “street language,” and
they may be less literal and purposeful in their
social interactions. Quite simply, social interaction
has a different purpose than a nurse’s professional
communication.
Therapeutic Communication
Therapeutic communication is “communication
between a health care professional and a patient
that is aimed at improving the patient’s physical or
psychological health and well-being” (Punyanunt-
Carter, 2013). The nurse understands that in order
to acquire certain desired information from the
patient, unique techniques of communication will
have to be instituted. Therapeutic communication
is purposeful: Nurses are trying to determine the
patient’s needs. If the patient is not comfortable
sharing his or her needs and concerns, the nurse
tries to uncover the problem by using techniques
of therapeutic communication and “active” or
“purposeful” listening (or “listening between the
lines”). The techniques of therapeutic communi-
cation are individualized to the patient and his or
her mental health disorder. The techniques and
blocks to them will be discussed at the end of this
chapter.
Neurolinguistic Programming
Neurolinguistic programming (NLP) is a form
of communication developed by John Grinder,
a psychologist and linguistics professor; and
Richard Bandler, a mathematician and editor
(Grinder & Bandler, 1981). It is a way of fram-
ing statements and questions to communicate
more effectively (see Chapter 9). The theory
builds on the idea that humans tend to interact
with the world in basically three ways: Hearing,
seeing, and touching. Choosing words that match
a patient’s primary way of interacting can make
a difference in how communication is actually
perceived by that patient. NLP can assist the
health-care provider in communicating more
effectively with the patient, which in turn may
lead him or her to change behavior and choose a
healthier lifestyle.
CHALLENGES TO
COMMUNICATION
Communicating is something that humans often
take for granted—until they no longer can do it:
For example, answering the telephone while
having laryngitis; trying to sign a legal document
while your arm is in a cast; or attempting to read
traffic signs after your eyes have been dilated.
These are uncomfortable situations, but they
are temporary. What about patients and cowork-
ers for whom disabilities are permanent? Trail-
blazer Bessie Blount Griffin understood some
of these challenges. She knew the importance
of providing soldiers who had lost their arms
with other means of writing, using their mouths
or feet.
CLINICAL ACTIVITY
Community Resources Worksheet
Contact an agency that provides services for
people with disabilities in your community. Explain
6913_Ch02_013-027 22/07/18 5:34 PM Page 17
Chapter 2
that you are a student nurse and that you are trying
to determine the resources available in your
community.
1. Name of person spoken with:
2. Name of agency:
3. Who are the target groups for this agency?
a. Gender(s)
b. Age(s)
c. Specific disabilities, such as speech, hear-
ing, and visual or other impairments
4. How do people access this agency?
5. What are the agency’s fees for services?
6. What types of insurance does the agency
accept?
7. What hours is the agency open?
8. Do people need appointments to come to
this agency?
9. Where does the agency keep patient records?
After your phone call, answer the following
questions:
10. What is your impression of this agency?
11. Would you feel comfortable coming to this
agency or referring a patient here? Why or
why not?
People Who Have Hearing
Impairments
The nurse must be patient when communicating
with people who are hearing impaired. The per-
son’s frustration is likely even greater than that
of the nurse. As with any other patient, try to
establish a trusting, team-approach relationship.
Let the person know you will try whatever it
takes for you to be able to understand each other.
Find out what has worked for that person in
the past.
Not all people with hearing impairments use
sign language; some use lipreading. However,
lipreading may be inaccurate and could lead to
miscommunication. Sometimes writing a note or
providing the patient with a journal is an effective
way to communicate with a person who is deaf or
hard of hearing. Keep in mind the key factor is
communication and not the patient’s grammatical
or spelling abilities.
People Who Have Visual Impairments
When a person is visually impaired, the nonver-
bal part of communication can be a challenge.
Nursing is a highly affective art, so certain non-
verbal cues, such as gestures, body position,
Basics of Communication 17
and facial expressions, “speak” most strongly to
patients. How does a sightless person or some-
one with low visual acuity interpret these non-
verbal cues?
Nurses must learn to become detail-oriented
storytellers. It is important to describe to the
patient the location of the call signal and what
the call signal sounds like, where his or her
belongings have been placed, and who has just
entered the room. Sightless people cannot see a
wave of the hand or see when someone leaves or
enters a room; these events must be verbalized.
Patient teaching for a person with a visual
impairment may involve physically moving or
touching him or her and verbally explaining in
much more detail than usual. Learning to feed
themselves can be difficult for a newly sightless
person. Usually, the teaching involves relating
the food position on the plate to the numbers on
a clock face. Sightless patients learn to rely on
their other senses to compensate for the eyes they
cannot use.
Sometimes individuals have more than one
communication challenge. For example, some
people have both hearing and visual impair-
ments. When communicating with these individ-
uals, a nurse needs to be creative. Investigate
methods that have worked for this person in
the past and explore methods such as a conver-
sation board or printing the message on the
person’s palm.
As emphasized in any nursing fundamentals
class, when entering the patient’s room, the nurse
needs to identify himself or herself, explain what
procedure is about to be performed, and make sure
the patient is safe. The nurse should also indicate
when he or she leaves the room.
People Who Have Laryngectomies
Some people live with partial or total
laryngectomy—the removal of their larynx
(“voice box”). Imagine being able to speak one
day and having no voice at all the next. The larynx
is a body part that is very much taken for
granted. How do these patients answer the
phone, order a pizza, express their emotions, or
call for help? When caring for patients with a
laryngectomy, provide them with a notebook and
a pen or pencil. A word or picture board can also
facilitate communication. Having the patient
type messages on a tablet or laptop computer or
a smartphone is another option.
6913_Ch02_013-027 22/07/18 5:34 PM Page 18
18 UNIT ONE Foundations for Mental Health Nursing
CLASSROOM ACTIVITY
Without using any verbal communication, ask a
partner to perform a simple task such as opening
a door, going from a sitting position to a standing
position, using eating utensils, or some other com-
mon activity of daily living. Then, trade places
with your partner.
People With Language Differences
Today’s society is global. Even though English is
the predominant language in the United States, it
may not be the primary language for many of the
people nurses work with and care for. As a nurse,
you may find yourself in an area where you are the
one who does not speak the primary language.
How will you communicate? How will you ensure
safe care of your patients? If a physician with a
thick accent gives a verbal order, how will you
know you have heard it correctly? Techniques for
ensuring understanding are discussed at the end of
this chapter.
CLASSROOM ACTIVITY
Working with your classmates, select 10 English
words and translate them into three other languages
(e.g., Spanish, French, or Hindi) using an online
translator app.
• Were you able to pronounce each translation
correctly?
• Which language(s) did you find particularly
difficult to pronounce?
People Who Have Aphasic/Dysphasic
Disorders
A person with aphasia has no speech, and a
person with dysphasia has great difficulty with
speech. The amount of speech a patient pos-
sesses is related to many things, including the
person’s age and the cause and severity of the
difficulty. Both aphasia and dysphasia include
damage to a portion of the brain. There are dif-
ferent types of aphasia (Table 2.1). It is impor-
tant for the nurse to know which type of disorder
has been diagnosed by the health-care provider
or speech therapist.
The health-care provider and the speech thera-
pist will determine the cause of the brain injury
TABLE 2.1 TYPES OF APHASIA
Types of Aphasia Description
Difficulty expressing
Expressive
himself or herself in
written or verbal forms
of communication
Receptive Difficulty interpreting or
understanding written
or verbal forms of
communication.
Global Combination of recep-
tive and expressive
forms of aphasia
and the extent of involvement, but the nurse will
be part of the patient’s plan of care. This requires
a very individualized type of communication skill.
An aphasic patient may try to read aloud a passage
from a book, but what comes out of the patient’s
mouth may be a long line of obscenities. The
patient would be very embarrassed if they knew
what they were saying. The nurse must be very
understanding and willing to try repeatedly to
communicate with persons with various forms of
aphasia. Nurses also must remember not to take
any “nasty words” personally; chances are very
good that the patient meant something entirely
different (see the section “Adaptive Communica-
tion Techniques”).
CLASSROOM ACTIVITY
Interview a representative from Americans with
Disabilities, your state’s Services for the Blind, or
any local agencies that serve populations with
special communication needs. Briefly share what
you learned with the class.
CLINICAL ACTIVITY
During your clinical rotation, ask your instructor to
assign you to care for a person with a communi-
cation challenge. Describe how you altered your
usual communication patterns to work with this
individual.
6913_Ch02_013-027 22/07/18 5:34 PM Page 19
Chapter 2
THERAPEUTIC COMMUNICATION
It is possible to have a helping, therapeutic conver-
sation with most people, but it takes some practice.
These techniques need to be practiced in much the
same way that one learns any other language: by
hearing them, practicing them, and making them
part of one’s professional (and social) vocabulary.
Before reviewing therapeutic communication
techniques, some examples of ineffective commu-
nication, where there is a breakdown in a message
will be reviewed. The following are examples of
communication block that impedes helpful inter-
action with patients:
1. False reassurance/social clichés. These are
phrases nurses may use to sound supportive.
In social communication, these expressions
sound friendly; but in a therapeutic relation-
ship, they invalidate the patient’s concerns.
Example Effect on Patient
“Don’t worry! • Tells patient his or her
Everything will concerns are not valid
be just fine.” • May jeopardize patient’s
trust in nurse
2. Minimizing/belittling. These, too, are used
socially to try to relieve the tensions of others.
Saying that many people are experiencing the
same thing as the individual is somehow sup-
posed to make the problem seem lighter. In
therapeutic use, the implications are different.
Example Effect on Patient
“We have all • Implies that the patient’s
felt that way feelings are not special
sometimes.”
3. “Why?” This simple word needs to be elimi-
nated in therapeutic interactions. Why connotes
disapproval or displeasure. The patient often
does not know why they did or said something
but may feel responsible for providing an
answer anyway. The nurse needs to use less
stress-producing methods to find out “why.”
Example Effect on Patient
“Why did you • Patient feels obligated to
refuse your answer something he or
breakfast?” she may not wish to
answer or may not be
able to answer
• Probes in an abrasive way
Basics of Communication 19
4. Advising. Alcoholics Anonymous sometimes
uses the statement, “Don’t ‘should’ on your-
self.” Nurses also must not “should” on their
patients. This sets the stage for expectations
that the patient may not be able to meet. It
also sets up, in the patient’s mind, some sort
of value system that puts the nurse’s value
as the “right” one. In addition, giving advice
can sound very judgmental.
Example Effect on Patient
“You should • Places a value on the
eat more.” action
“If I were you, • Gives the idea that the
I would take nurse’s values are the
those pills so “right” ones
I would feel • Sounds parental
better.”
5. Agreeing or disagreeing. Socially, people
agree or disagree for several reasons. Some-
times people are just expressing their opin-
ion. Sometimes they are trying to make a
favorable impression. Therapeutically, it is
wise for nurses to avoid statements that
express their own opinions or values. The
health-care provider does not want the patient
to dismiss his or her own personal opinions
and values.
Example Effect on Patient
“You were wrong • Places a “right” or
about that.” “wrong” on the
“I think you’re right.” action
6. Closed-ended questions. These are forms
of questions that make it possible for a one
word “yes” or “no” answer. They discourage
the patient from giving full answers to the
questions. Closed-ended questions are those
that start with such phrases as “Can you,”
“Will you”, “Are they”, and “May I.” It
does not help to add please, as in “Please,
may I ask you a question?” or “Will you
please take out the trash?” This courtesy
still leaves the possibility for the receiver
to say “yes” or “no.” The please makes the
question sound more polite in social venues.
To make the questions assertive and thera-
peutic, state or request what you want
(“I need to ask you a question” or “Please
take out the trash”). Closed-ended questions
limit the patient’s options for disclosure to
the interviewer.
6913_Ch02_013-027 22/07/18 5:34 PM Page 20

20 UNIT ONE Foundations for Mental Health Nursing

Adding words like how and what to the may answer quickly and move on to a more
beginning of a close-ended question can turn comfortable topic, such as, “Well, your
it into an open-ended question. physician has advanced your diet; that’s
Closed: “Can I help you?” good news!”
Open: “How can I help you?” or “What can
Example Effect on Patient
I do to help you?”
The patient is • Discounts the impor-
Example Effect on Patient asking a question tance of the patient’s
“Can you tell me • Allows a “yes” or “no” about his/her need to explore per-
how you feel?” answer prognosis, and sonal thoughts and
“Do you smoke?” • Discourages further the nurse responds, feelings
“Can I ask you a exploration of the topic “Did the doctor • May be a reflection
few questions?” • Discourages patient say anything about of the nurse’s own
from giving information discharging you discomfort with this
today?” topic
7. Providing the answer with the question.
This is a technique that television interview- 9. Approving or disapproving. This is similar to
ers use frequently. For instance, an inter- minimizing or agreeing. Approving or disap-
viewer may ask, “Didn’t you know that proving puts the nurse in the position of the
the committee would reject the proposal?” expert; and, in many ways, the nurse is. The
A better, more neutral way to ask this ques- nurse’s role, however, is to be supportive with-
tion is, “What were your thoughts about out being judgmental or imposing a personal
how the committee might react?” Occasion- idea of what is right or wrong, good or bad,
ally, the body language of the interviewer on the patient.
or the sender may influence the receiver’s The nurse is in a partnership of sorts with
answer. the patient. The nurse collaborates with the
patient to determine the best way to help the
Example Effect on Patient
patient help himself or herself. If the nurse can
“Are you afraid?” • Combines a closed-
look at the relationship with that attitude, there
“Didn’t the food ended question with a
is no “right” or “wrong” because each person
taste good?” solution
is different. No two patients are the same, so
“Do you miss • Discourages patient
what is helpful to each one is “right” for that
your mom today?” from providing his or
patient.
her own answers
Example Effect on Patient
8. Changing the subject. Nurses sometimes do
“That’s the way to • Can sound judgmental
this inadvertently. When schedules are busy
think about it!” • Can set the patient
and several patients need a nurse’s attention
“Good for you!” up for failure if the
at the same time, it is very easy for a nurse
“That’s not a good approval or disap-
to pass over a patient’s question or concern
idea.” proval does not help;
and then proceed with the nurse’s own
can lower the nurse’s
agenda. Unfortunately, that may send the
credibility
message to the patient that the nurse does
not care or that this problem is not worthy
of a nurse’s time. This patient may be reluc- Techniques of Therapeutic/Helping
tant to offer more information to that nurse Communication
in the future. Hildegard Peplau envisioned the nurse as a “tool”
Changing the subject may also reflect the for ensuring positive interpersonal relationships
nurse’s discomfort with the subject. If the with patients. Nurses are with the patient for ap-
nurse just experienced the death of a loved proximately 8–12 hours daily. Compare that with
one from a heart attack, for example, the the amount of time a health-care provider spends
nurse may be very uncomfortable answering with the patient, and it is easy to see how the nurse
a patient’s questions about recovery and prog- becomes the therapeutic tool that helps the patient
nosis following bypass surgery. The nurse help himself or herself. This observation was
Another random document with
no related content on Scribd:
"How's the research project coming, sir?" I asked as we sipped our
drinks.
"We have a variant of the FS-flu now that sterilizes only monkeys. It
may be the weapon we're looking for." He paused and looked
mischievously at Pat. "Did you know, by the way that the original FS
virus does not cause permanent sterility in primates?"
I caught the glance and her look of dismay.
"Primates? You mean humans too?"
He nodded. I turned to Pat.
"Then you aren't sterile? You didn't tell me you had a biopsy."
This time Hallam laughed outright. "How many months have you
been away soldier?"
"My God! Pat ... you're pregnant!"
She came to me. "Yes darling. I am. I didn't want to tell you because I
might miscarry again: but I went to Ray Thorne and he says I'm doing
just fine."
"Oh baby," and I pulled her into my arms. "What a wonderful,
wonderful Christmas!"
It was after dinner. We sat around the fireplace in silence. To one side
the Christmas tree, with its tinsel streamers and glass ornaments,
threw back a shower of sparks in answer to the flames. The coffee
was finished and I savored the last drop of Drambuie slowly, letting it
bite my tongue with its pungent sweetness.
"I wonder where Harry is," Polly spoke as she looked into the fire,
absently twirling the liqueur glass in her fingers.
"Have you had any news?" I asked.
"I got a letter this morning," she replied and added after a pause.
"They left for the Chinese mainland a week ago."
The wood crackled on the hearth and the room was silent again. I
thought of the bare brown hills of China; of the squalid mud huts like
those I had known in Korea; of the lice and fleas, the filth and bitter
cold; of the snow that sprinkled the stunted brush and dusted the
stubbled rice paddies. I thought too of the death that lingered in those
dank and sweaty rooms, black holes of fear and despair.
"God help them," I said fervently and added a little prayer for myself
in the days to come.
Polly began again. "He wrote the letter on the assault landing craft
and sent it back with the Navy. Apparently they had not managed to
perfect a vaccine before they left Formosa so the party is unprotected
against the measlepox. They hope to find enough survivors on the
mainland to collect anti-serum, provided they can keep away from
Red patrols."
"It's a shame they couldn't have waited another couple of weeks," the
Chief spoke up.
"Why so?" Pat asked.
"I got news this morning that our agents in Russia have sent out more
of the vaccine, stolen by the partisans, I suppose. It should be
available in a day or so and some of it will be rushed out to the
research teams for their protection."
"Maybe they'll send another team with vaccine after the first," Pat
suggested.
"I surely do hope so," said Polly, "I'm real worried about that man."
 CHAPTER 12
The ache of parting was still gnawing at my belly like a peptic ulcer
when Blackie picked me up at the airfield in a jeep.
"My goodness, Colonel, I'm relieved to see you."
"Why? What gives? I'm on time."
"Yes sir, but the operation has been advanced, you see. We leave for
Japan in the morning."
"In the morning? Oh, no!" I snorted in disgust. "Isn't that typical."
The week after our landing in Japan, we moved out again with full GI
equipment. Our enemy clothing and arms went along in sealed
wooden boxes as cargo, not to be opened again until D-day.
Ostensibly, we were replacements for the Korean Military Advisory
Group on our way to South Korea. We landed at Kimpo Air Base,
near Seoul and then moved out by truck up the road past Uijongbu
into the wooded hills south of the defense line near Kumwha. In the
twelve years since I had come down that road for the last time, the
mud and thatched villages had been rebuilt. Now the measlepox had
ravaged, once again, the stoical population. Only a few were left, the
few who perhaps had fled to the mountains and stayed there starving
but afraid until the pestilence had killed and passed on. So it was
back to a familiar land I came—a land of silent hills; of hardwood
trees standing bare and cold above the brown earth and the dead
brown leaves of the Kudzu vine; a land of little streams that thawed in
the sheltered spots as the February sun rose higher in the cold dry
air.
We trained over the steep hills, marching up faint trails where the
woodcutters once had gone. In all that wild land there was silence—
the silence of the four-footed animals who, unknown to us except by
some chance meeting, watched our slow approach. The long nights
shortened into March and then through April. Still we waited. Rains
had come now, the spring rains, forecasting the steamy monsoon of
July. In the steep valleys grass showed green and the maroon-
petalled anemones had already conceived. At last the cherries were
in bloom. It was time to go.
The troop-carrying convertiplane dropped vertically down on the
freshly prepared landing strip shortly after dark. As soon as we were
loaded it took off, wavering slightly under the hammering blast of the
jet engines, and then went up, sidling over the dark trees that
encircled the strip, and drifting down the valley like one of their lately
fallen leaves. It swung west to go out over the Yellow Sea and then
circle back into North Korea. Our rendezvous was farther to the east
in the wild country close to the railway that ran up the east coast from
Wonsan to Hungnam. Perhaps we could lose the radar in those steep
valleys. It would have been suicide to attempt it from the east, across
the Sea of Japan, right into the Siberian tiger's mouth.

An hour later we were approaching the drop zone. There would be a

moon before midnight to help us make contact, but now it was dark,
better for concealment but difficult for recognition of our landing area.
The plane slowed, the red light came on. The pilot must have picked
up the signal from our agent.
"Get ready!" I shouted. The men shifted their packs and moved their
feet to get the weight distributed.
"Stand up! Hook up! Check your equipment!" One by one I called the
time-honored signals, the ritual so necessary before the jump. By
now the air crew had the door open and I looked out. Even with my
eyes accustomed to the darkness I could see little but the dark mass
of hills below us and the rough black line where they met the horizon.
Above, the stars were bright. To the east a faint paleness marked
where the moon was hiding. I looked down again and now a tiny
green light winked up at me. It was the dropzone and the all-clear
signal. The aeroplane passed on and then came back to make its
run.
"Stand in the door!" I yelled. My hand holding the static line shook
slightly and my thigh muscles were tight with cold and adrenalin.
"GO." The red light had changed to green and the first men were out.
Shuffling from the rear the rest followed swiftly and seemed to drop
on to each other's shoulders as they went through the door. The last
man went by. I stepped behind him and in the same smooth motion
went on out. The rush of air twisted me and a momentary black cloud
blotted the stars as the tail assembly passed over. The roar faded
and I floated, weightless and almost mindless, like a baby in the
womb, while my mental clock ticked the slow seconds. "Three
thousand, four...." The snapping of elastic and the rush of risers
behind my head stopped in a sliding jerk. I looked up. Above me a
black circle swayed. It was complete; no torn canopy to worry about.
Alive now, I looked around full circle. Faintly I saw two parachutes
below and in front of me as I glanced back the way we had come. We
were dropping quickly into a steep valley, the others at a lower level
where it widened somewhat. I could see outlines of the terraced rice
fields coming up to meet me. In that warm, wet air I could have made
it standing. The chute collapsed without a protest. I struck the quick
release and stepped out of the harness. "Pretty soft," I was thinking.
"I hope the rest is like this." Where the hillside joined the terraces I
found a trail that paralleled the line of our jump. I followed it down hill.
An hour later, we were all together. The slow speed of the plane, the
low jump altitude and the lightness of the wind had kept the sticks
from scattering. Nobody was seriously hurt. We buried the parachutes
in an overhanging bank under the Kudzu and began our march down
the path. As the protected one I was now about the middle of the file.
The moon was rising and the light was strong in treeless areas. We
kept to the blackness of the shadows as much as possible and made
a reconnaissance before crossing any open space. Our progress was
slow. It must have been another hour when the line stopped
advancing. A short time later a whispered message came back,
"Send the Colonel up front."
When I got there, Blackie and Pak were talking Korean to a small
man dressed in the ragged coat and baggy pants of a peasant. Pak
introduced him.
"This is Lee Sung. He has the password and knows all about us."
I took the small limp hand Lee Sung extended. "I am Colonel
Macdonald, the Doctor. What do you want us to do now?"
"I have a place where you can stay," he replied in excellent English,
with an accent that seemed familiar, though blurred with lack of use.
"We should go there immediately."

We followed him a short distance on the same trail and then turned
up a side valley where the cultivated land rapidly rose in steps and
narrowed to a point at the little stream which had watered the crops.
There we found the remains of a small village. Hidden behind a row
of thatched mud huts that faced the fields with eyeless walls, a
narrow courtyard opened abruptly to the main house. Overhanging
wooden beams and tiled roof had protected the white paper walls of
the recessed front porch from the weather. It was the house of a rich
farmer, rich for Korea that is, and still intact.
"This is where you stay," said Lee.
Makstutis took command. "Kim, set out your perimeter guard and get
the men settled down. No lights; no smoking; no talking. I'll take a
look around."
"Yes, sir," Kim moved them away. I followed Lee, Blackie and Pak
onto the verandah of the house, stepping quietly on the wooden
planks. Sliding aside one of the paper and wood panels, we bent our
heads and entered. Crouched over a shaded flashlight, Lee traced a
map laid on the grass mat floor of a small side room.
"Here's where we are now. Here's the Imjin River and the village of
Song-dong-ni. The virus factory is less than a mile this side of the
village." He indicated the spot. "It's about twenty miles from here over
the hills."
"What are the trails like?" Blackie asked.
"There's a small trail, a bit slippery in wet weather, that climbs the
ridge behind this house. It joins a wagon road that runs down the next
valley and then you cut over the watershed to the Imjin by another
trail. That one is good in all weather."
"Is it travelled much?"
"Not now. The villages over there were wiped out by the plague. I
doubt if there is anybody left."
"How do we go about contacting the Russian who's going to give us
the virus?"
"He's not a Russian, Colonel, he's a Pole. His name is Anders and he
is the senior virologist at the factory. He is a keen botanist and it's his
custom to wander alone over the hills almost every day collecting
specimens. He carries a burp gun in case he should meet bandits
although there's little chance of that nowadays. However, it is a good
thing to remember in approaching him that all strangers are suspect. I
try to catch him on these walks of his, so it's a matter of chance and
may take a day or two to arrange a meeting. In the meantime, may I
suggest you and your white officers keep out of sight as much as
possible. Your oriental soldiers can pretend to be living here
temporarily while searching for bandit gangs."
"What about food?"
"The farmer who owned this village had a well stocked store room.
You will find it at the back of the house. There is plenty of rice, root
vegetables, pots of kimchi ... you have eaten kimchi I presume ... and
other preserved foods."
"What about the measlepox, doctor?" Blackie asked.
"I doubt if the food was contaminated. Besides we had one shot of
that Russian vaccine before we left. It's a small risk."
"I envy you Colonel. My only protection is to run away," Lee said
wryly.
"How did people survive?" I asked.
"After they became aware of the danger some took to the hills and
some small villages escaped. They kept strictly to themselves and
killed anyone who attempted to force his way into their area. I have a
small fishing vessel at Wongpo. I took it out to sea and stayed there
by myself for several weeks."
"Then you have no family?"
"No, my father was an exile in England during the Japanese
occupation. I grew up and went to college there. We came back to
our ancestral home after the World War. He and my mother died very
soon afterwards. The Communists let me stay, mostly because they
think I am sympathetic to their viewpoint and I have made myself
useful to them. An agent has no business with a family anyway," he
concluded grimly.
We talked on for some time, clearing up the details of our plans. It
was uncomfortably close to dawn when he left.

CHAPTER 13
I had a headache—a sonofabitch of a headache to put it bluntly, and
my eyes felt as if some gremlin had got in behind them and was
squeezing hard on the eyeballs. It had started as a mild frontal pain
when I was talking to Lee and I put it down to the tension of the jump
and the subsequent march to our present camp. I'd felt a little chilly
too when we got here but the nights were still cold in the hills and we
cooled off quickly after exercise. I was sure the aching in my back
was due to the pack I had carried, about seventy-five pounds of
machine gun ammunition, grenades and some medical supplies for
emergencies. But it wasn't going away and I felt lousy. I was feeling
damned sorry for myself as I went to sleep. Seconds later it seemed,
my eyes were wide open again and throbbing.
"Damn it, this won't do!" I muttered, and unzipped the light sleeping
bag we carried. "Lord, I'm hot!" I searched the aid kit shakily. Finally I
located the APC's, communist version, and then decided to check my
temperature. It was 40° Centigrade, right on the line. I translated that
into the more familiar Fahrenheit ... 104°. The bar of mercury, slaty
grey in the early light, shimmered and wavered as I tried to hold the
thermometer still.
"Hell's teeth! What a time to get sick."
I went over the various possibilities, forcing myself to concentrate, to
think as clearly as I could. It was too soon to tell. It could be malaria,
or meningitis, typhoid or typhus.... I'd had shots for those two. What
about dengue? Or old friend influenza? My mind was wandering now.
"Too soon to tell," I said, and I swallowed the APC's. "Too soon to tell
... too soon to tell ... to tell. tell. knell. hell. The silly rhymes echoed
down long empty corridors to my ears. I knew I was burning up and
getting delirious ... it felt like being drunk. Drunk? I'm not drunk ... I
never get drunk now ... nothin' to drink, drink, drink, nothin' to drink
and I'm hot. Oh God, my head! Must tell Blackie I'm sick. I have to tell
Blackie. I HAVE to tell Blackie!" It was important I knew and then I
couldn't remember what was important. I had to have water. I tried to
stand up.
There was a murmuring somewhere nearby but I couldn't locate it. It
persisted like a buzzing fly and I was annoyed. My head still hurt and
my eyes ached and I ached all over and I was hot and sticky and
thirsty and weak and that damned noise wouldn't go away. Wearily I
decided I'd have to do something about it. I tried to lift my head but
couldn't make it. I tried again and felt myself lifted. Ahead of me a
face wavered and then stabilized.

"Colonel Mac, Colonel Mac, can you understand me? Colonel

Mac...."
I blinked blearily at him. I squeezed gritty eyelids together and tried
again. It was Sergeant Jimmy Lee, my aidman. "Lee what is it?" My
mouth was dry and it was hard to talk.
"Sir, we don't know what's the matter with you. Can you tell us?"
I shook my head and it tried to fall off. Lee propped me up again.
"You've been out of your mind for three days now and running a hell
of a fever. I sponged you and gave you APC's. I even gave you a shot
of penicillin when we thought you were going to die." His young face
screwed up with worry.
"I've still got the fever, haven't I?" I muttered weakly. "It feels like it."
Makstutis came into focus beside Lee. "It's down some, Doc, but your
face was red as a tomato and your eyes are still all bloodshot. Your
urine was bloody too. Now you've got little red marks, kinda like
bruises, on your skin."
"Eyes all bloodshot ... little red marks." Somewhere a circuit snapped
shut in my head. "God Almighty! I've got Songho Fever."
"Songho Fever? What's that, Doc?"
"It's called Epidemic Hemorrhagic Fever in the States, and it hit a lot
of G.I.'s around the Iron Triangle in the Korean War."
Jimmy wasn't too young to remember. He had been in on the tail end
of that fight.
"You must have picked it up around Kumwha," he said. "There's
nothing you can do for it is there?"
"No more than you are doing now, unless the Reds have something
we don't know about." I sipped the water someone brought and lay
back.
Blackie had come in when he heard I was conscious. "Lee Sung is
back," he said. "Maybe he could get something from Anders, or better
still, get Anders to see you."
"I couldn't walk two minutes, let alone twenty miles."
"By Golly, we'll carry you," said Blackie. "Don't you worry Colonel." I
fell asleep again with his comforting hand on my shoulder.
The trek across the ridges was rough. I can't remember much of it
except the feeling of falling when the improvised stretcher tipped on
the steep slopes or someone lost his footing. By now, one of our
sergeants, another Korean War veteran named Lim On, was ill with
what appeared to be the same disease and the morale of the unit
was slipping. We had jumped a week ago and as yet had
accomplished nothing. In a deserted, half-collapsed farmhouse about
a mile from Song-dong-ni, they laid Lim and me down on piles of
straw while most of the men bivouacked in small dugouts
camouflaged in the woods beside the house. We waited for Lee Sung
to get Anders.
He arrived the following afternoon. A tall man, he looked like a
benevolent hawk, pale smooth hair, sharp nose, keen grey eyes. He
stooped under the low lintel of the hovel and stood for a while in the
semi-darkness of the tiny, paper-walled room until his eyes were
adjusted. Then he came and dropped on one knee by my side.
"You are a very sick man, Colonel," he said slowly, in precise English.
"I think I have hemorrhagic fever," I said.
"There is little doubt," he agreed as his hands searched my neck and
armpits for swollen glands. "See, the small blood spots on your
abdomen, and your eyes. And what else have you noticed?"
I gave him the story, including what Makstutis had told me about the
bloody urine.
He nodded his head. "Yes, it must be so. I cannot now prevent it, but I
can help you to get well." He took a syringe and a bottle of solution
from the small pack he carried. "Lee Sung told me. I brought serum.
Every day you must take a dose, and the other man, too. I have no
doubt he will have the same disease."
It was probably some sort of concentrated convalescent serum. I
never did find out; but it seemed to help. There was no more bleeding
and the fever dropped. Lim improved too and, fortunately, none of the
others seemed to have caught it. I was still terribly weak and
somewhat depressed but I was able to get around a bit by the end of
our second week in North Korea.
The days dragged along and my strength was slow to return. I read
and re-read the letter I had received just before the take-off from
South Korea.
"I am getting along fine," Pat had written, "in spite of feeling
somewhat bloated and clumsy, which, after all, I must expect. We had
some more news about Harry. Apparently the raiding party he was
with got ashore all right and set up their headquarters in one of the
small villages near the coast. They seem to be getting along real well
so far.
"I am so glad Polly is staying with me, we are good company for each
other. When I got the letter from General Rawlins that told me you
had left, I was relieved in a way, as I had wondered why you didn't
write. Now at least I know and I am sure you are glad that, one way
or another, it will soon be over. I don't expect to hear from you again
until your mission is completed. Darling, please be careful. The
General told me you had had shots for the measlepox, (they sent
some out for Harry's team too), so I am not quite so worried. At least
the dangers you face will be those of a soldier and you will have a
fighting chance."
"She obviously had never heard or had forgotten about hemorrhagic
fever," I thought ruefully, the pages trembling in my fever-weakened
hands.
"Dr. Hallam is often over to see us in the evenings," she continued. "I
believe he is really fond of Polly ... and she of him ... but naturally he
doesn't express such feelings. If anything happens to Harry I'm sure
he will take care of her."
"And who will take care of you and the baby if I don't come back," I
thought as I crumpled the letter and burned it. We shouldn't have
carried that last batch of mail into the airplane. It was the one
sentimental chink in our disguise. As soon as I was well enough I
checked to be sure that everyone else had destroyed all mementoes.
I was not naive enough to think that we could keep our secret if
captured, but pages of letters could be misplaced or fragments blown
away and picked up by anyone coming into the area.

The Rangers kept busy. Only one or two remained in the house to
cook and look after Kim and me. The rest lay low during the day and
reconnoitred by night so that they were soon familiar with the layout
of the virus factory and the surrounding country. They briefed me on
every trip they made until I felt I knew it almost as well as if I'd seen it
myself.
That week, Anders came three times. We always had guards posted
and, once he knew he was safe, he relaxed and talked quite volubly
in Russian or English.
"It may be fortunate for you that you have had Songho Fever," Anders
said, during one of these early talks.
"Why so?"
"The western world has not yet discovered the cause of it, but we
have."
He was obviously proud of the achievements of his laboratory, in
spite of the horrible use to which they had been put.
"It's a very simple virus, carried, as you suspected, by mites which
live on small rodents. We have now taken that virus and changed it
so that it does not require to pass through other animals as part of its
life cycle. It can now pass in droplets of sputum from one man to
another. In the process of change it has become much more virulent,
almost one hundred percent fatal, I would say, with an incubation
period of only one or two days. Also it is now extremely infectious
and, I believe, far worse than the measlepox. That is the virus we
have begun producing, in large quantities, in our factory."
"What are the symptoms of this new disease?" I asked.
"It acts much like the natural disease except for its extreme rapidity.
There is a tremendous increase in the hemorrhagic tendency, with
fatal bleeding into the gastrointestinal tract, the urinary system, or
sometimes the lungs. The victims die in shock within forty-eight
hours, as a rule."
"How do you know how it will act on human beings?" I said curiously
although I thought I already knew the answer.
"Our people are more realistic than yours," he said, quite sincerely.
"We offered men condemned to die a pardon if they lived after being
exposed to the virus. Most of them agreed."
"I'm surprised they got a choice," I said acidly.
"Our rulers have softened since the days of Stalin," he replied with a
wry smile.
"Why didn't you use it instead of the measlepox?" I asked him.
"We did not have enough, and also we did not have a vaccine against
it until recently. In fact only a few people have been protected. I am
one, and so are my helpers in the Laboratory ... and, to some extent,
so will you be for a while."
"Do you really think so?"
"We have found there is limited cross-immunity from having had the
natural fever, especially early in convalescence, but that protection
wears off rapidly."
"What do you mean by limited?"
"Let us suppose you had an accident with the vials I shall give you for
your return journey and spilled the contents on you. You would be
very ill with the fever but you would have a fair chance of living."
"Have you given the new syndrome a name?"
"Yes, a melodramatic one. We call it the bleeding death."

In the third week of our stay he came unexpectedly, late on a

Wednesday afternoon. I talked to him alone as the other officers had
gone on an early patrol. He was extremely agitated.
"I believe the counter-offensive will soon be starting," he said. "The
Americans have refused to sell any more food to us and our radio is
full of reports that the return of another wet spring in Europe and
drought in Siberia is their doing. Today we were ordered to load all
our available virus for shipment to Russia. We expect to send it
Saturday."
"How will it go?"
"In refrigerated tank cars," he replied, and seeing my amazement, he
added, "We do not have a bottling plant here. There are barely
enough immune technicians to load it and seal the containers
properly. I have been told there is an automatic bottling plant in
Siberia which can put the virus in missile warheads without human
aid, but of course I am not completely informed about these things."
"God! They must be desperate if they intend to let this thing loose on
America without being immunized themselves."
"A calculated risk, Colonel. We can produce vaccine rapidly and
protect those who matter before the disease rebounds to our lands."
"Those who matter! That's good! I'll give you three guesses who
makes the decisions."
On their return that night I called in my officers and explained the
situation.
"We must stop that stuff from getting out of here," I said at the end.
"In fact, if possible we should blow up the tank cars and let it all run
out and at the same time try to put the laboratory out of action. It
won't do much good now for us to take the virus home ... there would
be too little time to produce a vaccine against it even if we have the
formula."
"There's a railway bridge about two miles from the plant, about four
from the way we'd have to go, that crosses a deep ravine," Makstutis
said. "It's on the spur line from the main Wonsan-Vladivostok railway.
That's the only way out of this fever factory of theirs. We can put
demolition charges on that to blow when the train goes over. There's
only three or four bridge guards. I'm sure we could cut the telephone
wire and handle them before the train gets there."
"Suppose not all the tank cars are destroyed," Kim said. "Could they
use that crap again, or would they go near it?"
"Yes, they would," I said. "Some of the technicians are protected by
immunizations."
"Then somebody has to be designated to explode the tanks in case
they survive the drop," Blackie said. "And what about the train
guards?"
"You're so right!" I said. "That makes me the mouse that ties the bell
on the cat. You boys hold off the guards, I'll get the tank cars."
"Hell, Doc, you've lost your marbles!" Makstutis burst out in
amazement. "That's our job. We've got to keep you all wrapped up
like a dame in mink so you can tell them back home what's in that
lousy stuff."
I laughed at his pop-eyed indignation. "That's true ordinarily, Mak," I
said, "but this new virus is one hundred percent fatal if you get it.
Anybody who blows those tanks is likely to get some on him,
especially since they'll be damaged by the fall into the gorge. But
people who've had this hemorrhagic fever are partly protected,
especially while they are in the convalescent stage, as I am, so I'll
have to explode the tanks."
"I still don't like it, Colonel," Blackie said.
"Look, Blackie, if you get this new fever you die for sure ... and
probably all the rest of the unit will die too. Then how do I get back to
the States?"
"But if you blow it, sir, we can't bring the formula home," Kim said.
"That's true, but that's the lesser of two evils. We must destroy the
virus, and if possible the factory too, before they shoot the stuff over
to North America. If we don't, knowing the formula will be like a
condemned man knowing how he's going to be executed ... what
difference will it make?"
"Geez, Colonel, I don't know," Makstutis began.
"I do," I cut him short. "And I'm going to get those tanks. That's an
order. It's certain death for anyone else."
"Except me, Colonel." Lim On stood up as tall as five feet three would
stretch. We had forgotten him sleeping in the corner on a pile of straw
and he had heard the last part of our argument as our rising voices
awakened him. He looked about as pale as a yellow-skinned man
can, which to me seems more a ghastly green, but he was steady
enough, and determined enough to argue with me when I tried to set
him down.
"Colonel, I'm the demolitions man of the section," he persisted. "I'm
as fit as you are, and, if the Colonel will pardon me for saying so, I
know a lot more about it than you do."
"OK, Sergeant," I gave in, "I'll carry the charges and you set them."

The next day Anders was back again, his bird face no longer amiable
but haggard and harried. "The tank cars begin loading tomorrow
morning. I believe they will go out as soon as finished, which should
be shortly before sunset. The Commissar is worried about possible
sabotage and, I believe, has falsified the departure time." He
pondered for a moment and then looked at me. "Colonel, I am afraid
to stay here. May I go with you when you leave?"
"You may," I said slowly, "if you will do something else for us.
Otherwise I think it would be better if you pretend to know nothing
and stay behind." I explained our plan to wreck the train and then
added, "We will be concentrating on this attack and won't be able to
come back and pick you up. Obviously you will not be able to go with
the train after it is loaded so you could not find us. On the other
hand," I paused to estimate my man, "if we were able to have help to
get inside the camp and sabotage it, you could escape in the
confusion and come with us."
"But what about the formulae?" he asked anxiously. "Are you not
coming to get them from me?"
"We would like to have them, of course," I replied. "But it is not worth
the risk for them alone since there will not be time now for our people
to set up production facilities."
"You ask a lot of me," he said heatedly. "I could easily betray you and
stay in the factory. You could not remain here indefinitely."
I threw a trump card. "What makes you think the factory is going to
stay here indefinitely?"
His face seemed to sicken as I watched. "This means atomic
warfare," he said, "and the end of the world."
"If we have to die, you are going to die too. You have about two
weeks." I was exaggerating, actually it was two months. "If we don't
report success to our headquarters by that time, an atomic
submarine, armed with a Polaris missile with atom bomb warhead,
has orders to obliterate this whole area."
"No," he shook his head. "No—this is too much. I have had enough of
this killing. I will not betray you."
"I didn't think you would," I said drily.
"But I must come with you," he said. "I am afraid the Commissar is
becoming suspicious. Yesterday we were warned by intelligence to
expect parachuting American raiders and the political commissar was
asking me about my botanical excursions. He doesn't like me anyway
because I am a Pole, and he may have put someone to watch me
and report on my movements." I looked at Blackie and he raised his
eyebrows. Was this a shrewd guess on the part of the Russian G-2
people or had some of our rangers been picked up?
"Poor devils," I thought. "They're probably being brainwashed right
now. Time is running out on us, for sure. We must get moving right
away."
Anders was saying, "What do I have to do for you?"
I told him my plan, slowly and carefully.
"One thing more," I said, as he started to go out the door. "Don't
forget to bring samples of the viruses and vaccines with you ... and
anything else you may think important."
"I will do that," he promised. "Goodbye and good luck, Colonel."
When the sound of his steps had faded, Blackie spoke again.
"You're taking quite a chance, Colonel. He knows enough now to ruin
us all."
"Yes, I am. He is a proud man and I played on his pride as a scientist.
Deep down, he probably is ashamed of having prostituted his
discoveries for the purpose of murder, even though there wasn't
much he could have done about it. He wants to make amends and I
think he will go with us. Anyway, I could see no other way of doing it,
could you?"
I looked around the circle of officers squatting on the rice mat floor.
"We're with you, Doc," Makstutis said. "All the way, by heaven."
Three heads nodded in agreement.

CHAPTER 14
At last light we sent out a small party to set up a diversionary attack
behind the factory. There was a little gully screened by low bushes
that seemed a suitable place from which to fire. It could not be
approached in the daytime without some danger of observation. The
plan here was to bury small charges on the railway line to be fired
from the gully just after the train had passed. This would twist the rails
and prevent the engineer from backing up to the factory again. A few